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Pathology of the Cardiovascular System

Heart Failure

Dr. Omar Emad Ibrahim

PhD in Pathology
Senior Lecturer in Pathology / Histopathology
Consultant Histopathologist
Centre of Preclinical Sciences Studies
Faculty of Dentistry
Universiti Teknology MARA ( UiTM)
Common Clinical Problems
From Cardiovascular Disease
Common Clinical Problems From Cardiovascular Disease
Heart failure
• The human heart is a remarkably efficient, durable, and reliable pump
• Propels over 6000 liters of blood through the body daily
• Beats more than 40 million times a year
• Providing the tissues with a steady supply of vital nutrients
• Facilitating the excretion of waste products
• Cardiac dysfunction can be associated with devastating physiologic
Heart failure
• Heart failure is a common multisystem disorder characterized by :-
• abnormalities in cardiac muscle
• skeletal muscle
• renal function
• There is stimulation of sympathetic nervous system, activation of the
renin–angiotensin–aldosterone system and other neurohormonal
Heart failure
• In most patients with heart failure the cardiac output is reduced and
this causes a degree of underperfusion that is called arterial
Heart Failure

• Heart failure, often called congestive heart failure (CHF), is a common,

usually progressive condition with a poor prognosis
• CHF occurs when the heart is unable to pump blood at a rate
sufficient to meet the metabolic demands of the tissues or can do so
only at an elevated filling pressure
• it is easiest to understand the pathology of heart failure by
considering right- and left-sided heart failure separately.
• With the increasing use and enhanced technical quality of
echocardiography it has become clear that there are abnormalities in
both systolic and diastolic function in heart failure
Left Ventricular Systolic Dysfunction
• In about 60% of patients with acute heart failure syndromes (AHFS)
the ejection fraction (the proportion of blood ejected into the aorta
with each heart beat) is reduced
• often in proportion to the clinical severity of the disease.
• This is termed left ventricular systolic dysfunction (LVSD).
Heart Failure With Preserved Ejection
Fraction (HFpEF) (diastolic heart failure)
• Up to 40% of cases the ejection fraction is preserved but diastolic
relaxation of the ventricles is impaired.
• Although the ventricles can contract well, their filling is impaired.
• This was originally called diastolic heart failure but is now termed
heart failure with preserved ejection fraction (HFpEF)
Congestive Heart Failure
Left-sided heart failure

• Is most often caused by:-

1. ischemic heart disease
2. hypertension
3.aortic and mitral valvular diseases
4. myocardial diseases
Left-sided heart failure

• The morphologic and clinical effects of left-sided CHF primarily result

1. congestion of the pulmonary circulation
2. stasis of blood in the left-sided chambers
3. hypoperfusion of tissues leading to organ dysfunction
Left-sided heart failure

• Dyspnea
• on exertion
• at rest
• Orthopnea
• redistribution of peripheral edema fluid
• graded by number of pillows needed
• Paroxysmal Nocturnal Dyspnea (PND)
Left-sided heart failure
PND (Paroxysmal Nocturnal
Blood tinged sputum
Elevated pulmonary “WEDGE”
pressure (PCWP) (nl = 2-15 mm Hg)
Right Sided Heart Failure
• Etiology
• left heart failure
• cor pulmonale most commonly associated with parenchymal
diseases of the lung
• The common feature of these diverse disorders is pulmonary
• Symptoms and signs
• Liver and spleen
• passive congestion (nutmeg liver)
• congestive spleenomegaly
• ascites
• Kidneys
• Pleura/Pericardium
• pleural and pericardial effusions
• transudates
• Peripheral tissues
Right Sided Heart Failure
“Dependent” edema
Hepatomegaly (congestion)
Increased peripheral venous pressure
(CVP) (nl = 2-6 mm Hg)
Right Sided Heart Failure
• The clinical features of isolated right-sided heart failure are those
related to systemic (and portal) venous congestion, and include
hepatosplenomegaly, peripheral oedema, pleural effusions, and
Right Sided Heart Failure
Pitting oedema

Pitting oedema

Heart failure cells

Nutmeg liver
Congestive Hepatomegaly
Chest X-RAY Normal

Chest X-RAY Cardiomegaly duo to congestive heart failure

Septal lines, also known as Kerley lines, are seen when the interlobular septa in the pulmonary interstitium become
prominent. This may be because of lymphatic engorgement or edema of the connective tissues of the interlobular septa.
They usually occur when pulmonary capillary wedge pressure reaches 20-25 mmHg.

Kerley A lines
These are 2-6 cm long oblique lines that are <1 mm thick and course towards the hila. They represent thickening of the
interlobular septa that contain lymphatic connections between the perivenous and bronchoarterial lymphatics deep
within the lung parenchyma. On chest radiographs they are seen to cross normal vascular markings and extend radially
from the hilum to the upper lobes. HRCT is the best modality for the demonstration of Kerley A lines.

Kerley B lines
These are thin lines 1-2 cm in length in the periphery of the lung(s). They are perpendicular to the pleural surface and
extend out to it. They represent thickened subpleural interlobular septa and are usually seen at the lung bases.

Kerley C lines
Kerley C lines are short lines which do not reach the pleura (i.e. not B or D lines) and do not course radially away from
the hila (i.e. not A lines).

Kerley D lines
Kerley D lines are exactly the same as Kerley B lines, except that they are seen on lateral chest radiographs in the
retrosternal air gap 2.